Clinical approach to diagnose CSOM and its types and its homoeopathic therapeutics

Dr Tamanna Kochar

Definition- Chronic suppurative otitis media is a long standing infection of a part or whole of the middle ear cleft characterized by ear discharge (ottorhoea) and permanent perforation of tympanic membrane.¹

Etiology-Environmental (it is common in hot and humid climates), genetic, previous history of persistent acute otitis media, upper respiratory tract infections or route of infection through eustachian tube, blood borne.¹

Types of chronic suppurative otitis media –

1. Tubotympanic type (safe type)
2. Atticoantral type (unsafe type)

Clinical features–  Ottorrhoea, Hearing loss (conductive type), Tinnitus^.

Otoscopic examinations-  Discharge, perforation (central in Tubotympanic type and marginal in Atticoantral type), polyps, granulation.

Investigations- Otoscopic investigations and Tuning fork test (to measure the level of hearing loss), Imaging Ex-mastoid X –ray, CT done in Atticoantral type for complications like cholesteatoma.²

How to differentiate between types of chronic suppurative otitis media through observation and symptomatology.

1. Intermittent or continuous discharge- in safe type ( tubotympanic) there is intermittent discharge and in unsafe type ( atticoantral) there is continuous discharge.
2. Character of discharge- In safe type there will be mucosal discharge and in unsafe type there will be purulent discharge.
3. Quantity of discharge- Quantity is profuse in safe being mucousal  CSOM and scanty in unsafe CSOM being epithelial cholesteatoma.
4. Odour of discharge- Foul smell discharge drains from unsafe type, fungal infection(otomycosis), malignancy, mixed infections, gram positive and majority of gram negative anaerobic bacteria invasions and enzymatic degenerations which leads to foul smelling discharges, while odourless discharges drains from safe type of CSOM.
5. Blood stained discharges – Causes of blood stain discharges are unsafe CSOM, trauma, malignancy and vascular masses. Blood stained discharge are present in unsafe CSOM as it is mainly a disease of epithelium or squamous tissue or cholesteatoma it grows, it has a property of destroying whatever comes in its way, it destroys the bone, vessels and nerves. It has high chances of complications, development of granulations ,development of degeneration and all this leads to blood draining from the ear.
6. Aggravating factors – Aggravating factors are upper respiratory tract infections, because if there are upper respiratory tract infections in case of safe or mucousal type the infection spread from upper respiratory tract via the Eustachian tube to the middle ear, and whenever the patient takes medicine it get recovered ,so disease or discharge which improves with medication and aggravate with upper respiratory tract infection, think in terms of safe CSOM, while unsafe CSOM will not have any aggravating nor any relieving factors.
7. Reduced hearing – Fluctant hearing loss- Meniere disease,perilymph fistula,otitis media with effusion.We can make out from the way the patient is talking, if it is conductive the patient feels monotonous low sounds (mumbling and soft sound),the speech is low pitch and in sensory neural hearing loss the patient will speak loudly ,they usually have lack of speech discrimination so when we talk to patient he will say he is missing out few words, so clarity of sound is not there in SNHL.

Other-
Vertigo- It is caused by mainly two causes, one is labyrinthitis which is ear temporal complications and second is cerebellar abscess which is intracranial complication .

Facial symmetry- is asked to rule out any complication like facial nerve paralysis, drolling of saliva or asked to open or close the eye.

Headache – is asked to rule out intracranial complications like meningitis, extradural or subdural abscess and even brain abscess can lead to pain.

Diplopia- to rule out petrositis or petrous apicitus.

Homoeopathic therapeutics for CSOM

1. BARYTA CARBONICA for prevention.³
2. CARBOLIC ACID (physical exertion, even much walking , bring on abscess in some part, but generally in right ear)³
3. SILICEA (Suppuration with a vent, chronic OTITIS MEDIA, abscesses, fistula) ⁴
4. KALI BICHROMIUM (Chronic suppurative OTITIS MEDIA with perforated tympanum; with ropy string discharge),INSULINUM (Enlarged liver with suppurative conditions i.e., chronic suppurative OTITIS MEDIA, boils, carbuncles, sinuses, suppurative tubercular glands with enlarged liver)⁴
5. HEPAR SULPHUR( Suppurative tonsillitis, OTITIS MEDIA, corneal ulcer, leucorrhoea, whitlow, suppuration in the bones, necrosis and caries.⁴
6. THIOSINAMINUM Suppurative OTITIS MEDIA. Thickened eardrum, catarrhal deafness with scar thickenings. Deafness due to some fibrous change in the nerve, adhesions of the Eustachian tube. Eustachian tube catarrh.⁴
7. MERCURIUS SOLUBILIS {Recurring OTITIS MEDIA with foul, green discharge that is acrid and offensive. Tendency to eardrum rupture. Sharp, stabbing pain in the ear. Fetid ear discharge)⁵
8. PSORINUM (otitis media rupture of drum; prolonged discharge from such an abscess; foetid discharge. “Otorrhoea with headache; thin, ichorous and horribly offensive like spoiled meat; very offensive, purulent; brown, offensive from left ear, for almost four years”.⁶

Bibliography

1. Dhingra.P.L.- Shruti Dhingra ,Disease of Ear ,Nose& Throat-Reed     Elsevier India pvt.Ltd.- 5th edition- p.69,77,78.
2. Sinha vikas- vikas sinha PRACTICAL –Jaypee Brothers, Medical Publishers Pvt. Limited 2017- 3^rd edition.
3. Allen H.C.-Keynotes arranged and classified with Leading Remedies of the Materia Medica and Bowel Nosodes.New Delhi:B.Jain publishers (P) LTD-Tenth edition;2005.
4. Mathur K.N.- Systematic Materia Medica of Homoeopathic  remedies. New Delhi:B. Jain publishers(P)-edition;2017.
5. Murphy N.D. Robin – Nature’s Materia Medica. USA:Lotus Health     Institute- 3^rd Edition;2006.
6. Kent J.T.-Lectures On Homoeopathic Materia Medica. Philadelphia:Boericke &Tafel 1923- 3^rd Edition.

Dr. Tamanna Kochar
(MD-1 Scholar) , Department of Materia Medica
Sri Guru Nanak Dev Homoeopathic Medical college, Ludhiana(Punjab).